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This kind of thing makes me really cross and question the sanity of the medical profession.
Although no one likes to contemplate the passing of a loved one, one must also face the facts and recognise, as Dr Willet Whitmore said, may years ago: Growing old is invariably fatal; prostate cancer is less so.”
A man aged 89 in the US today has a life expectancy of between two and six years with a median of a little under four years. Of course statistics can never be applied precisely to an individual, but it seems reasonable to suppose that your father, with his heart condition, may not live for much longer than the maximum statistical expectation of six years.
Is he likely, on the basis of the information you have set out, likely to pass on was a result of prostate cancer within this period? That is doubtful and, if that is so, then why possibly hasten the end with what certainly seems to be inappropriate and unnecessary surgery.
My remarks about the surgery are based on the fact that what an orchidectomy achieves is the reduction of the production of Testosterone and dihydrotesterone (DHT) which are said to fuel the growth of prostate cancer tumours; what the Lupron therapy has been doing for the last 20+ years is precisely the same thing – stopping the production of Testosterone. So what on earth would be achieved by the surgery now?
The current medical opinion would be that your father’s disease has become Hormone Independent (there are other phrases such as Androgen Independent, HIPC, AIPC, etc if you want to do searches on the subject) and IF this the case then cutting off the supply of Testosterone will not make any difference, simply because it is not the Testosterone that is fuelling the growth now – if indeed there is significant growth.
When you say His PSA levels have been creeping up over the years. , would you like to expand on that to give some idea of how rapidly the creep has occurred and if indeed the PSA levels have consistently doubled and re-doubled at an increasing rate – the basic indicator of a rapidly growing tumour that has managed to find a way to fuel itself outside of the Testosterone system. The example you give In January 2010, his levels were at 2.3 and in April 2010 they were at 2.5. is not really indicative of anything simply because it is not possible to measure PSA accurately to one decimal place. Most laboratories will only guarantee an 80% accuracy, so results should be given showing the range of the result i.e. 25% each side of the median. This would demonstrate clearly that the two readings are in fact in the same range and do not necessarily represent and change in the PSA levels (If you have not been there and are interested in some of the dynamics of PSA tests you might like to go to PSA 101
I think your best bet would be to get your father to the best oncologist you can find – especially one who specialises in prostate cancer and discuss the entire issue with them. It certainly seems to me that you are not getting the best advice from your current doctors.
My responses to your specific questions follows – I trust that you will be aware that I have no medical training whatsoever and everything I know about prostate cancer is based on what I have learned since my diagnosis in 1996.
I hope this helps
Terry in Australia
1. Why are you recommending that my testicles be removed e.g. PSA levels alone? An excellent question that needs to be dealt with fully – there seems no reason for doing this at this stage.
2. Should I take other lab tests to get a better picture of the situation e.g. ultrasound, physical exam, urine tests? What about a blood test to test for circulating prostate cancer cells or a biopsy? There are very few tests that come to mind that will provide any further information of value. If a DRE (Digital Rectal Examination) has not been carried out lately, it might be an idea to se if any growth can be felt on the site of the removed gland. A Color-Doppler scan MIGHT show some signs of tumour growth; a nuclear bone scan MIGHT highlight any metastasis to the bone, but the most likely situation seems to be that IF the PSA creep is due to prostate cancer, this would likely be systemic or even metastasied and therefore potentially very difficult to spot.
3.Is there a recurrence of my prostate cancer (or other cancer?) or is this purely a preventive measure? It seems likely that the assumption is that the diseas is no longer in remission and that it has recurred.
a. If I do have a recurrence of cancer, what clinical stage do I have e.g. t1c, t2a, t2b/c? The clinical staging only applies to initial diagnosis. Technically, if there is evidence from the scans suggested that there is metastasis, the staging would be T4. b.What is my Gleason Score? Unless a tumour can be identified and biopsied (unlikely) it would not be possible to establish a Gleason Score. c.Has the cancer metastasized? Perhaps.
4.I read that prostate cancer is one of the slowest growing cancers. What would be my life expectancy if I have the surgery versus if I didn't have the surgery? I touched on this above – there is more at THE ELEPHANT IN THE ROOM
5.This surgery seems pretty radical, are there any alternative treatments (e.g. radiation, etc)? EBRT (External Beam Radiation Treatment) might be an option if it is clearly established that the PSA is being generated from tumour growth in the vicinity of the removed gland, that area might be radiated: on the other hand if metastasised disease is clearly identified, from the bone scan for example, some targeted radiation might be considered. But in reality the chances are greater that, if the PSA is prostate cancer related, then it is systemic and the entire body should be treated, rather than create further damage with radiation.
6.I am 89 and I am on anti-coagulant drugs for a heart fibrillation. I would need to stop taking the drugs 10 days prior to surgery. What are the risks of this surgery for an 89 year old man with a heart fibrillation? I can’t estimate that beyond expressing the view that anaesthesia for men over the age of 75 is often regarded as hazardous, even if they are in excellent health.
7.How long will I be in discomfort after the surgery? Reports I have read is that recovery is usually a brief period – but then I have not read of any man of 89 having this procedure – and inevitably recovery is longer as we age.
8.Will I need any specific post-surgical care? Will I need someone to help me and if so for how long? How should I care for my surgical wounds? I have no data
9.I have some incontinence issues, how will that affect my wounds? Will urine sting my surgical wounds, prevent them from healing, or cause infection? I have no data
The only thing that I know about his PSA levels was that it started at .1 shortly after his prostatectomy in 1987. I'm not exactly sure what my father meant by "shortly." Perhaps a year or more, and I don't know what stage he was at when he had the prostatectomy.
All the details of his original diagnosis would help a new doctor to gain a better understanding of what might be happening now, but clearly any disease that was dorman, or under good managment for 20+ years is not likely to 'leap forth' an expand rapidly.
One thing I meant to mention is that there is a chance of osteoporosis developing with long term use of the hormone therapy your father has been on. It would be a good diea to check his bone strength.
Would a urinary tract infection cause a PSA to rise? I thought I read that somewhere. I believe my dad had a UTI around his most recent test but he doesn't remember. I'm still verifying with my sister though as my dad's memory is a bit hazy.
Would a urinary tract infection cause a PSA to rise?
is
YES
Bladder and prostate gland infections are the principle cause of elevated PSA results. PCa is the minority cause. PSA is NOT PCa specific. See PSA101as suggested above.
About 12 years ago my PSA went from 2.2 to 7 and a biopsy (only 2 samples as my urologist was an old guy)showed nothing. My new younger urologist thought I has prostatitis which was cured with antibiotics. PSA declined back to 2.2
